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Date run 615/2007 8:30:07AM SAN JOA -IN COUNTY ENVIRONMENTAL HEALr"' DEPARTMENT Report#5021 <br /> Run by r '%Of, Pagel <br /> Facility Information as of 6/5/200 <br /> Record Selection Criteria: Facility ID FA0000107 <br /> Make changeslcorrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0000091 New Owner ID <br /> Owner Name MANI, SUBAR <br /> Owner DBA DE VILLE APARTMENTS <br /> Owner Address 7501 S EL DORADO ST <br /> SAN BRUNO, CA 94066 <br /> Home Phone 209-983-0458 <br /> Work/Business Phone 209-430-1341 <br /> Mailing Address PO BOX 960 <br /> FRENCH CAMP, CA 95231 <br /> Care of MANI INVESTMENT <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000107 <br /> Facility Name DE VILLE APARTMENTS <br /> Location 7501 S EL DORADO ST <br /> FRENCH CAMP, CA 95231 <br /> Phone 209-983-0458 <br /> Mailing Address 4D�"969 �7j C' <br /> FRENCH CAMP, CA 95231 ^ <br /> Care of MANI INVESTMENT <br /> Location Code 99- UNINCORPORATED AREA APN:19316044 <br /> BOS District Q01 -GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000106 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility / Account <br /> Account Name DE VILLE APARTMENTS (Circle One) <br /> Account Balance as of 61512007: $470.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4242-WASTE WATER TX PLANT PR0420069 EE0007379-AMANDA BOERTIEN Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State andlor Federal Laws. ` l <br /> APPLICANT'S SIGNATURE: �! -` — Date LP 1 Lk 1 �� <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date 1 1 <br /> Payment Type Check Number Rece' ed by <br /> REHS: Date I ! Account out: Date <br /> COMMENTS: <br /> llphs-ehsgl-ntlappslenvisionslreports15021.rpt <br />